A keynote address given at the Council of Occupational Therapists
for the European Countries' (COTEC's) 8th European Congress of
Occupational Therapy, Hamburg, 22-25 May 2008, hosted by the Deutscher
Verband der Ergotherapeuten e.V. (German Association of Occupational
Therapists).

Key words: Ageing in place, assistive technology, older people.

Introduction

The number of people aged 65 years and over in Europe will be
around 25% in 2030 (AGE--European Older People's Platform 2007).
There are several reasons behind this increase in numbers of older
adults. One reason is that people live longer because they live
healthier lives; another reason is that it is now possible to treat
previously incurable medical conditions. Perhaps as a result of this
increase in numbers, we will see many more older adults participating in
society; for example, working until a very old age or travelling the
globe as grey backpackers. The question of this keynote address is: what
can occupational therapy contribute to a society with a large population
of older people?

We know that this increase in numbers of older adults in Europe
will mean that it will be more common to have people with impaired
hearing, with low vision and with less muscle strength, as well as
people with cognitive problems, since these are problems that increase
with old age. A population of people who live longer and longer also
means more people with participation restrictions.

An implication of the increase in numbers of older people is that
Europe will have to make society more accessible (Iwarsson and Stahl
2003). Making daily living for older adults easier will need to be high
on the European agenda. This also suggests that new services will need
to be developed in local communities. Overall, Europe will be required
to become more inclusive to all people when the population includes more
older adults. This could mean that ideas about 'design for
all' and inclusive design (Clarkson et al 2003) will become more
accepted and lead the way for new developments in Europe.

It is a huge challenge for European countries to handle the
increase in numbers of older people and the most urgent need for our
societies is to identify good ideas to make them stay healthy for as
long as possible. Governments, the European market, health care
providers and agencies and local communities want to learn how to enable
older people to continue to engage in and participate in society. In
response to this, occupational therapy can argue that we have ideas for
new programmes and new evidence-based services to do this.

Our proposal to Europe is to learn from occupational therapy.
Occupational therapy offers some useful concepts and good ideas, which
can serve as driving forces to make Europe more inclusive and enhance
the participation of older adults. In fact, occupational therapy could
have a key role in future developments for older people, since we have
the ideas, the visions and the knowledge that the European countries are
now requesting.

The good ideas

One of the good ideas, which is also a cornerstone of occupational
therapy, is: occupations can contribute to people's health and
wellbeing (Kielhofner 2004, Wilcock 2006, Christiansen and Townsend
2009). This is a fundamental idea of our profession and a reason why
occupational therapy is being recognised as having an essential role in
health care provision.

The question that we need to ask ourselves is: what does this idea
mean today for older people in Europe? It means that we believe that if
we support and enable older adults to engage in occupations, especially
people with activity limitations and participation restrictions, they
will also stay healthy for a longer time. Wilcock and Townsend (2009)
note that older adults should not be deprived of doing the everyday
tasks that they have always been doing just because they are old. Older
people should not be left:

What I believe that we can offer from occupational therapy is ideas
about:

* New occupationally based services in the community to support
older adults

I would like to share some examples of what occupational therapy
can contribute. The first example is a community intervention of a
project related to the prevention of falls. This demonstrates how
occupational therapy can contribute to society to develop services.

Falls prevention: a community intervention

For white Caucasian women over 80 years of age, almost 50% face the
risk of falling and a fracture (Gillespie et al 2003). In some parts of
the world, a hip fracture means death, while in other places it means
restrictions in daily living. From an occupational therapy perspective,
it is not only a bone that is fractured but also life itself, because it
is difficult to manage everyday occupations after a hip fracture
(Peterson and Clemson 2008). The good news is that occupational
therapists know that people themselves can do much to prevent falls, as
long as they have access to the knowledge on how to do this.

The project fallfritt (www.fallfritt.se), which emerged from the
Karolinska Institutet, is best described as a 'community
intervention'. The project started with a campaign to recruit
people outside the health care system to become 'falls prevention
activists'. We recruited, for example, opticians, pharmacists,
podiatrists, caretakers of buildings, and assistants in shoe shops.
These people all provided services to older adults at risk of falling
before they fell, in contrast to health care personnel who meet older
people after they have fallen.

The activists who were recruited were then educated by occupational
therapists about how to prevent falls. The underlying idea was that the
activists, through their normal jobs, would be able to make suggestions
for prevention for people at risk; for example, older people with
impaired vision or poor balance or just people with poor shoes. In
addition, the activists would also become more knowledgeable about what
occupational therapists can do for people at risk of falling and suggest
that they contact an occupational therapist.

Apart from initiating the campaign, the contribution of
occupational therapy was to provide research-based knowledge and
information about what can be done and what people can do themselves to
reduce the risk of falling. This was achieved through lectures,
workshops and club meetings. This project, which is now being evaluated,
is an example of how occupational therapy can be a part of, and create,
new services to the local community by contributing research-based
knowledge.

The key to the development of new programmes in occupational
therapy and new services in the local community is research. More
research is an urgent investment for occupational therapy in Europe.
Doing research or not doing research could be the difference between the
profession having an impact or not. In order to initiate the right kind
of research projects that will support older people, we should ask older
people about their expectations and needs. In research, we need to ask
the same questions as we do in our practice: what do you want to do and
what do you need to do? What do you dream about for the future?

Doing-with assistants

From an interview study with older women, we learnt that one wish
for the future from women living in an urban Swedish environment was for
them to receive assistance from people that came to their home to
accompany them in different activities. This was not as traditional home
helps do, but in a new and different way. So these assistants would not
be doing things for them, but doing things with them: a kind of
'doing-with assistant', compared with the more traditional
home help.

It was not very sophisticated things that these women mentioned in
the interviews; it was just ordinary daily activities. For example, the
assistants should help with shopping for food or doing the laundry. The
assistant should make activities easier to perform and the older person
would still make all the important decisions.

Doing-with assistants should be educated and trained to be
supportive to older adults in daily living, without taking over the
activities and without depriving older people from engaging in
occupations. The idea about doing-with assistants is strongly related to
the principles of occupational therapy. By making it easy for people to
be engaged in occupations as long as possible, they will stay healthier
for a longer time. Coaching doing-with assistants could also be a part
of an occupational therapy programme to be developed in the future. This
relates to the importance of being client-centred and including the
family in our interventions. We will probably soon develop educational
programmes or groups where relatives, families, spouses and perhaps
groups of volunteers will come to be trained and educated to become the
new doing-with assistants. However, there are also other options: what
if this doing-with assistant could be a robot?

Robots

A robot is not a very expensive assistant and could serve as a
doing-with assistant to carry home the shopping, to reach objects, to
carry the laundry or to do the vacuum cleaning. Perhaps a robot could be
shared, for example with neighbours. It could become a reason to meet
and talk to other people for those without a family or friends nearby.

Most older adults in the west would say: 'No, I do not want a
robot in my house.' This may be because what we fear most is that
our parents, ourselves and the people that we love and care about will
end up lonely, without anyone caring for them but a soulless robot.
Nobody looks forward to that kind of future.

It is interesting, nevertheless, to learn how technology can evoke
many types of feelings. Robots in the west may be seen as a threat,
something that is almost evil. However, robots, or any kind of
technology, are not evil or good in themselves. Robots are more accepted
in parts of Asia than they are in Europe and they are especially popular
in Japan. Technology is in itself neutral. It is the use that human
beings make of it that provides it with meaning. That meaning is also
influenced by culture (Asaba et al 2009) and becomes evident when we
compare cultures. If we take a deeper look at the issue, we would find
that this also has to do with cultural beliefs, values and ideas.
Japanese companies are developing robots designed for care and
housekeeping, and my guess is that it is also going to be possible to
get caring robots in Europe soon.

One reason for discussing robots is that I think that occupational
therapists should participate much more in the design and development of
new technology. The great advantage that we have as occupational
therapists is that we can observe and evaluate technology in
occupations, in daily living and in real life. We should do more
critical reviews of new technology based on our practice, since
technology will be extremely important in the care of the older adults
in the future. Studies by European occupational therapists have also
shown how the importance of technology increases with age, so the older
you get the more likely it becomes that you will need technology to
assist you (Lofqvist et al 2005).

In the future, I think occupational therapists should become
experts on the use of technology for older people. In addition, we
should do more: not just to evaluate the use of technology but also to
invest in new inclusive designs and assistive technology, together with
experts from other disciplines. A great example of an investment for the
future based on research is the development of new assessments and
different types of measure for occupational therapy. So, next I will
outline some research on a new assessment in progress.

Everyday Technology Use Questionnaire

The Everyday Technology Use Questionnaire is being developed by my
colleague and PhD student, Louise Nygard (Rosenberg et al, in press). In
developing this assessment, the team asked older people with and without
cognitive problems what kind of technology they used in daily living.
Based on this inquiry, it was possible to say something about their
competence to use ordinary everyday technology.

The increase in numbers of older people in Europe also means an
increase in numbers of people with Alzheimer's disease and other
kinds of dementia, because the incidence of dementia increases with age.
Enabling people with dementia to stay at home and live independently
will be a very difficult challenge for families and communities and for
the welfare systems in Europe.

Occupational therapy in Europe needs to suggest how to provide
better support for older adults with dementia. Some of these ideas might
relate to the information technology behind 'Smart Homes' and
supportive home environments, which has the potential to provide support
to people with dementia. This technology can, for example, remind people
with dementia when it is time to eat, take medication or watch their
favourite television programme.

The implications are that people who make use of this type of
technology might feel more safe and secure and might also be more
included and part of the community. Even if there is potential in
technology, we also need to see beyond that and think about what
occupational therapy can do in terms of empowering older people to
engage in occupation. One example of research that has the potential to
do that is Occupational GAPS.

Occupational GAPS

My colleagues at the Karolinska Institutet, Gunilla Eriksson and
Kerstin Tham, have, through some interesting studies, identified what
they named Occupational GAPS (Eriksson et al 2006). An occupational gap
is defined as the gap that occurs between what a person wants and needs
to do and what he or she actually does in domestic activities, leisure
and social life, as well as in work. This is also close to what Clark
and her team identified in the Well Elderly Study (Hay et al 2002).

In a recently published study, the researchers from the Karolinska
Institutet were able to identify a strong association between the extent
of occupational gaps and life satisfaction among people who had acquired
a brain injury 1-4 years earlier (Eriksson et al 2006).

First, this indicates that our ideas and beliefs are accurate:
occupations can influence health and wellbeing. Secondly, it tells us to
base practice on research like this: if occupational therapy can fill
the gaps, occupations can change people's lives. Then occupational
therapists need to include the ideas about occupations in therapy. Both
in practice and in research, we ask questions that do not have a simple
answer. The questions occupational therapists ask and the aspects that
we want to learn more about are different from those that physicians,
doctors, nurses, physiotherapists or social workers ask. Occupational
therapists want to know how occupations influence people's health
and wellbeing. The occupational perspective makes us ask people: what do
you enjoy doing? How do you spend your time every day? What is important
for you to do? What activities are most rewarding and valuable for you?
We ask questions that the other health professions do not ask!

Through our unique perspective, we see the world differently from
other disciplines and we add something new to the full picture. When we
apply an occupational perspective (Kielhofner 2004, Wilcock 2006,
Christiansen and Townsend 2009) and implement the ideas about how
occupation can influence health and wellbeing in our research, we
suggest new, interesting and innovative results. We can open new avenues
to people's lives when we ask these questions. Here is a
preliminary definition of what an occupational perspective can be in
research:

Why do I speak about this? I want to stress that the research we do
in occupational therapy has the same focus as the profession has and
that the ideas, values and beliefs that underpin the profession and make
the profession's contribution to the society unique are the same
ideas, beliefs and values that also make occupational therapy research
unique.

I will provide more examples of research that applies the
occupational perspective in research. One of our PhD students at the
Karolinska Institutet, Lisa Ekstam, was able to show, through an
occupational perspective in research, how the spouses of people who have
had a stroke experience the same kind of loss of occupations as the
person with the stroke. It became clear that the relationship between
the couple was filled with dilemmas related to occupations. This study
informs practice about the need to include spouses in occupational
therapy, to pay attention to patterns of occupation in both partners and
to tailor the occupational therapy programme based on this.

In another study, La Cour et al (2005) suggested that occupations
in terms of doing a creative activity can enable the creation of
connections to daily life and enlarge the experience of self as an
active person, even in the face of an uncertain life-threatening
illness. It was possible to identify this knowledge through an
occupational perspective. Andersson-Sviden et al (in press) identified
the meaning of occupations to older persons who visited a social
day-care facility. The older adults enjoyed various occupations to the
extent that it did not matter if they became tired or even experienced
pain after engaging in occupations at the centre. The participants
valued the doing so much that they could choose to manage with pain
after engaging in occupations.

All these examples are qualitative studies with an occupational
perspective. The benefits of doing qualitative studies are that they
deepen our understanding of the context for daily living for our clients
(Borell et al 2006), which also helps us to identify, as occupational
therapists, what older people need. This is also why we need studies
that can inform us about people's experiences, since there are
always situations that we need to understand beyond the obvious. These
studies also include a grounded view in philosophy on, for example,
understanding or meaning (Ricoeur 1984, 1985, 1988), and they often
build on interpretations. I think that it is time for us to take the
philosophers out of the closet and make them speak to us and support our
ambition to be rigorous and to be grounded in philosophy.

Why are occupational therapists in Europe so interested in
conducting qualitative studies?

One immediate answer would be that it is because occupational
therapists ask clients the kinds of question that require information of
a qualitative nature as opposed to studies that only apply statistics as
a method. Qualitative studies are interested in how older people
experience technology, daily life or living with a disability. We give
voice to the clients in studies where they are treated like participants
instead of anonymous objects. This relates to the humanistic beliefs of
our profession.

Occupational therapists want to understand the things that we do
not understand and to find answers to the questions that we have in
order to develop the best possible support to clients. We are good at
finding ways to understand better and ask the right questions in
practice. We need to do the same in research. We need to raise our
expectations and be more critical in how we design and do the research.
Descriptive studies are not enough; we need to progress, become more
sophisticated, and conduct qualitative studies that can inform theory
building and speak to a wider audience.

There is a need, however, for studies that inform us through
numbers and statistics. For the future, we need to walk on two legs. For
example, we need to conduct quantitative research that provides evidence
in numbers of, for example, the effects and outcomes of occupational
therapy programmes for older people. Numbers are powerful tools that we
should use. We also need valid and reliable measures, based on an
occupational perspective, that will tell us how occupations can
contribute to people's health and sense of wellbeing. Future
studies, including those with older people, need to be intervention
studies where occupational therapy practitioners and researchers create
and evaluate occupational therapy programmes and new technology for
older adults.

Of special importance will be large-scale studies, conducted on a
European level, instead of just in the local community or national
studies. There are still few examples of larger studies in occupational
therapy. However, Iwarsson and her colleagues from Lund University have
initiated studies of this type, the ENABLE-AGE Project (Iwarsson et al
2004). We should all learn from that project.

The shared master's programme in occupational therapy and
occupational science is also a promising place for collaborating in
research at a European level. Overall, we need to create more
collaborative efforts in the future. We need to work to make groups of
creative practitioners and researchers come together to share ideas and
develop our research in occupational therapy.

Conclusion

Occupational therapists can work together to meet the challenges
that Europe is now facing in terms of the huge increase in numbers of
older adults. To achieve this, occupational therapists need to develop
innovative and effective programmes and initiate new services in the
community. Occupational therapists are well suited to contribute
knowledge, since the values, beliefs and ideas that we share, related to
how occupations contribute to people's health and wellbeing, could
be the ideas that Europe applies to meet the needs of the older adults.

Occupational therapists can be experts on design and usability
issues. In relation to technology, occupational therapists should move
from being consumers and prescribers to become designers and developers,
participating in the design and development of new technology and
services.

Research will be a key factor for occupational therapy in Europe in
the future. Occupational therapy will become acknowledged as an
important part of the European welfare system, especially in the
provision of support for older people.

In order to develop new and much needed theory and programmes for
the ageing society, occupational therapists need to do much more
research. This research should emerge from our unique occupational
perspective, in contrast to a medical or social perspective that limits
our vision and constrains our thoughts. This occupational perspective
focuses on the development of knowledge about how occupations relate to
health and wellbeing.

Research in occupational therapy and research in occupational
science will both have different methodological approaches, which will
need to be refined and developed further. For this reason, we will need
to build creative groups of occupational therapy practitioners and
researchers, who will work for the shared goals of change and
development in Europe and in the rest of the world.

Acknowledgement

Thanks to Christine Craik of the Editorial Board of BJOT for her
assistance in preparing the manuscript for publication.

Sitting alone in nursing homes or other confined settings
with nothing to do ... (p196).

An occupational perspective in research refers to the study
of human engagement in occupations in time and place.
In this way, an occupational perspective seeks to discover
and describe how participation as well as the experience of
doing relates to health and wellbeing.